Cycle 1
Health 2025-03-20 · Fire 2025-03-20
12 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Grapevine, TX
Bear Creek Nursing And Rehabilitation
2-star overall rating with 1-star inspections with $142,612 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3729 Ira E Woods Avenue, Grapevine, TX
(817) 527-7500
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
2016-07-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,881
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.33
Baseline 23.59% · Performance 22.39% · Measure score 1.33 · Achievement 0 · Improvement 1.33
Healthcare-associated infections
7.51
Baseline 9.61% · Performance 5.91% · Measure score 7.51 · Achievement 6.43 · Improvement 7.51
Total nurse turnover
3.74
Baseline 68.49% · Performance 50.00% · Measure score 3.74 · Achievement 3.35 · Improvement 3.74
Adjusted total nurse staffing
0
Baseline 3.22 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 8.7% · Lower 95% interval 6.91% |
| Discharge to community | 59.96% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 145 · Observed rate 55.17% · Lower 95% interval 51.71% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.17% |
95.27%
2.9 pts better
|
Numerator 107 · Denominator 109 |
| Falls with major injury | 0.92% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 109 |
| Discharge self-care score | 62.32% |
53.69%
8.6 pts better
|
Numerator 43 · Denominator 69 |
| Discharge mobility score | 66.67% |
50.94%
15.7 pts better
|
Numerator 46 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 6.42% |
2.29%
4.1 pts worse
|
Numerator 7 · Denominator 109 · Adjusted rate 5.51% |
| Healthcare-associated infections requiring hospitalization | 5.91% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 108 · Observed rate 4.63% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 148 |
| Staff flu vaccination coverage | 0.52% |
42%
41.5 pts worse
|
Numerator 1 · Denominator 191 |
| Discharge function score | 69.57% |
56.45%
13.1 pts better
|
Numerator 48 · Denominator 69 |
| Transfer of health information to provider | 90.77% |
95.95%
5.2 pts worse
|
Numerator 59 · Denominator 65 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.26% |
25.2%
20.9 pts worse
|
Numerator 2 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.8 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.1
1.4 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
97.9%
2.8 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
3.3%
1.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.4% · Q4 2.3% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
18.9%
6.2 pts worse
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 28.6% · Q3 25.0% · Q4 26.7% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
10.8%
8.3 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.8% · Q3 0.0% · Q4 2.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.4% |
15.4%
4 pts worse
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 17.5% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
16.1%
6.2 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 37.5% · Q3 13.5% · Q4 5.1% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
0.8%
1.6 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 2.0% · Q4 4.1% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
15.0%
4.3 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 20.7% · Q3 17.0% · Q4 22.7% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.2%
2.5 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.8% · Q3 4.6% · Q4 5.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
89.7%
2 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 90.5% · Q3 89.0% · Q4 85.9% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.0%
4.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.5% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.8% |
88.0%
1.8 pts better
|
79.7%
10.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
25.9%
2.3 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 25.4% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
8 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2022-12-07 · Fire 2022-12-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2025-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-08
F · Potential for more than minimal harm
2024-02-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-15
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-31
F · Potential for more than minimal harm
2024-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-31
F · Potential for more than minimal harm
2022-12-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-12-07
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-12-07
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-12-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-12-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-15
E · Potential for more than minimal harm
2022-12-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-31
Inspection history
Recent health citations
K · Immediate jeopardy
2025-12-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-22
K · Immediate jeopardy
2025-12-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-03-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-20
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-02-17
D · Potential for more than minimal harm
2025-02-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-17
D · Potential for more than minimal harm
2024-11-27
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-12-19
K · Immediate jeopardy
2024-10-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-20
K · Immediate jeopardy
2024-10-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-20
K · Immediate jeopardy
2024-10-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-25
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-02-15
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-02-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-02-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-02-15
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-03-31
E · Potential for more than minimal harm
2024-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-29
J · Immediate jeopardy
2023-10-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-20
D · Potential for more than minimal harm
2022-12-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-12-09
Penalties and ownership
What sits behind the stars
$69,300
2025-12-21
Fine
Fine · fine $69,300
Fine
$65,866
2024-10-25
Fine
Fine · fine $65,866
Fine
$7,446
2023-10-30
Fine
Fine · fine $7,446
Fine
Ownership
Maverick County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
Operational/Managerial Control · Individual
Grapevine Nursing And Rehab Center, LLC
Operational/Managerial Control · Organization
Martinez, Alma
Corporate Director · Individual
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